Contemporary Use of Glycoprotein IIb/IIIa Inhibitors in Patients with Left Ventricular Assist Devices

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Purpose The efficacy of glycoprotein IIB/IIIA inhibitor (IIB/IIA) use in patients who receive left ventricular assist devices (LVAD) has not been well studied. A prior single center study of eptifibatide use for pump thrombosis in almost exclusively HeartMate II (HMII) LVAD patients concluded that the risks of such use outweighed the benefits. We sought to analyze the outcomes of IIB/IIIA use in our more contemporary cohort of mixed axial and centrifugal flow LVAD patients. Methods We performed a retrospective analysis of all patients with LVADs implanted at Stanford Hospital from 2010-2018. We used the electronic medical record to identify LVAD patients who received IIB/IIIA inhibitors for suspected pump thrombus. Outcomes assessed included resolution of thrombus, need for pump exchange, and adverse events such as stroke and death. Results Out of 304 patients who had an LVAD placed during the study period, 42 (14%) received IIB/IIIA inhibitors after LVAD placement. Of this subset, 74% were male, 69% received HM II LVADs (31% HeartWare), 71% were implanted as destination therapy, and 88% received eptifibatide (12% tirofiban). The average time from implant to IIB/IIIA use was 278 days (SD 365). 50% of patients had clinical resolution of their thrombus (80% tirofiban, 46% eptifibatide, p = 0.14). 29% of patients suffered a stroke, all of whom were exposed to eptifibatide (0% tirofiban vs 32% eptifibatide, p = 0.15). 43% of patients went on to eventual cardiac transplantation, 45% required pump exchange (0% tirofiban, 51% epitifibatide, p = 0.02), and 19% died in total from thrombotic complications, including pump exchange. There were no significant differences in the rate of stroke, pump exchange, or death with IIB/IIIA use when stratified by type of LVAD (HMII vs HeartWare). Conclusion IIB/IIIA inhibitors can be effective in treating suspected LVAD pump thrombus, with resolution of thrombus in half of cases in our experience. Whether outcomes differ based on the type of IIB/IIIA inhibitor used requires further investigation. The high proportion of patients who died or required pump exchange/eventual transplantation suggests that the use of IIB/IIIA inhibitors carries risk, and the effect may not be durable. Identification of patients and clinical scenarios that minimize risk and improve efficacy of IIB/IIA use is paramount.